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Fatalities At West Fertilizer Company: Was The Enemy Of Safety Responsible?


Thirty years in the safety profession, countless hours of incident investigations, hundreds of reports later detailing how and why bad things happen to good people, and yet I find the end result is seemingly the same.

A safety process was not followed and therefore one or more people paid the ultimate price. Fellow safety professionals all over the world are undoubtedly shaking their heads because they too have seen the consequences of organizational risk-takers and their impact on employee and community safety.

So here it is, again. Another fatal industrial explosion. Another life, and another, and another gone in a series of souls and communities lost to an all too familiar theme: a risk not worth taking. You’ve read and heard the news. Officials still cannot determine the cause of the explosion at the fertilizer plant in West, Texas.

As with the BP tragedy in the Gulf not too long ago, the West Fertilizer Co. (owned by Adair Grain Inc.) explosion was caused by one event. That is correct, one event … the failure to follow safe practices. We just saved three months of investigations, fines, litigation, posturing, and everything else that follows these preventable and fatal events.

The official investigation, when completed, is sure to reach this forgone conclusion. Watch for it and compare the investigative results to this prediction. The question is why? The answer is just as evident and predictable as the cause of most fatal industrial accidents: incremental rationalization.

Rationalization is the process we all follow when we want that piece of chocolate but know we should not have it. The only thing holding us back from instant gratification is the knowledge that the calorie intake for the day will likely exceed the calorie burn rate and that usually means more fat production and storage in our bodies.

Incremental rationalization occurs when you reach a final decision little by little and not all at once. It is the battle of tiny voices in your head; one devising reasons to act, the other one shouting the reasons not to. You are caught in the middle.

The process goes something like this in our heads:

  1. I should not have it.
  2. Well, I know I should not have it but maybe if I work out a little more a little later, I can have it.
  3. Hmmm … I will not have time today but tomorrow I can walk at lunch rather than sit through it and exercise after work.
  4. Okay, I’ll just have half the piece (munch). Now I only have to exercise tomorrow half the time.
  5. Well … Okay, it is true that you only live once.
  6. I should have it

Incremental rationalization takes us from steps 1 through six very methodically to the point of convincing ourselves that the eventual outcome is the right answer even though we know, deep down, that it is not.

Incremental rationalization can be good and bad depending on the situation. It is one of those intellectual tools we use to help us make tough decisions. When it comes to following safety processes, however, incremental rationalization is the enemy of safety.

How does incremental rationalization cause fatalities? It acts to establish new levels of acceptance or new norms. Today I can stack a little bit more on that anhydrous ammonia pile because when I did it yesterday, nothing happened. The additional small shovel-full tomorrow becomes a mound. Next week, the mound gradually becomes a hill. The following month, the hill slowly becomes a mountain of 54,000 pounds of anhydrous ammonia. Nothing happens. A new norm is now established. Steps one through six and nothing has happened … or has it?

The mountain is now a means to an end for a small community in West, Texas without regard to the consequences because nothing has happened so far. Until finally, the flexible fabric of safety, stretched beyond its elastic limit, snaps under the tremendous tension place upon it by the process of incremental rationalization and BOOM.

Incremental rationalization does not discriminate when pitted against safety. Refineries, fertilizer plants, oil rigs, even your home is susceptible to its wrath. Your safety is no match for it.

So how can these incidences be prevented? How can our communities be safe? How can our families count on their loved ones returning home safely after a hard day at work? How can our heroic first responders not die at work trying to save those who are in peril, at work? How can we simply be safe earning a living? It takes all of us and all of them, whomever they are. We/they must not rationalize away our safety nor the safety of others for any reason and under any circumstance. Not even a little bit. It is simply not worth the risk.

Leaders everywhere, when the stakes are high, take action against incremental rationalization early so your safety program has a chance to do what it is designed to do … Protect people and the surrounding communities. What action you ask? Well, establish a culture that chooses to leave the chocolate on the table.

Read more posts by J.A. Rodriguez Jr. here. J.A. Rodriguez Jr. is a contributing blogger for JenningsWire.


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